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Organ systems vs. body areas

N

ncgirl

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87
Location
Cumming, GA
Can we use the bullet points from '97 guidelines to determine body areas and organ systems to audit under '95 guidelines?

Also when you are checking for the hernias/masses or obtain a stool sample, does it come under GI system or abdomen (body area)?

Does Exam of scrotal contents (hydrocele, spermatocele, tenderness of cord, testicular mass) & penis come under body area or organ system?

Last question - does exam of urethra (masses, tenderness, scarring), cervix (general appearance, lesions, discharge, adnexa/parametria (masses, tenderness, organomegaly, nodularity) come under body area or organ system?

Please clarify. It'll be very helpful. Thanks in advance!
 
ncgirl said:
Can we use the bullet points from '97 guidelines to determine body areas and organ systems to audit under '95 guidelines?
Click to expand...
Of course.

ncgirl said:
Also when you are checking for the hernias/masses or obtain a stool sample, does it come under GI system or abdomen (body area)?
Click to expand...
Checking for hernias sounds like a musculoskeletal finding, but masses could be a GI finding. For example if they say the abdomen is soft, nontender with normal bowel sounds, no masses or hepatosplenomegaly. They are looking for masses that could be a sign of tumor (benign or possibly cancer), infection (diverticulitis), or Abdominal Aortic Aneurysm. You could count this as GI findings or you could list it as the body area Abdomen.

Obtaining a stool sample doesn't typically count as part of the physical exam, but it is counted as Data being reviewed - which factors into the overall Medical Decision Making complexity.

ncgirl said:
Does Exam of scrotal contents (hydrocele, spermatocele, tenderness of cord, testicular mass) & penis come under body area or organ system?
Click to expand...
Of course, the organ system would be Genitourinary or the body area would be Genitalia, groin, buttocks.

ncgirl said:
Last question - does exam of urethra (masses, tenderness, scarring), cervix (general appearance, lesions, discharge, adnexa/parametria (masses, tenderness, organomegaly, nodularity) come under body area or organ system?
Click to expand...
Same as the last one. the organ system would be Genitourinary or the body area would be Genitalia, groin, buttocks.
 
Last edited:
Thank you so much!

I think I did not ask my question clearly. One of our colleagues argues all the above mentioned as "body areas" ONLY when you are counting for the exam component of E/M. In other words, you can not give credit to organ systems to any of the above mentioned when you audit under
'95 guidelines if these are found in the provider's documentation.

Do you agree?

Thank you once again!
 
You can absolutely count them as an organ system. I'm not sure what logic your colleague would use to argue that an exam of the scrotal contents and penis cannot be considered a genitourinary exam. You can count it as an exam of that organ system, or the body area, but not both.
 
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